documentation at delivery

OOO I have another question, after reading that thread about documenting mity-vac usage. I know documentation practices vary from place to place, and I am definitely asking the CNS about this when I work next, but what are some things you definitely need to include in a delivery note? Where I work there is a delivery record that is filled out by the physician (with the check boxes for nuchal cord, episiotomy, vacuum/forceps use, etc....and they are really lax about filling it out sometimes, let me tell you) and the RN's documentation is all on the labor notes, so usually at delivery there is a longer narrative note.

For example, with a mity vac assisted delivery I would chart when it was applied, any pop-offs, but it had never occurred to me that I should be charting mmHg used with it. Documentation is not addressed in detail in our policy/procedure binder either except as it applies to fetal monitoring (I think in our "Care of the Labor Patient" policy it states something like "document entire delivery procedure")

Just wondering what others do. thanks!!

Just to give you an illustration regarding documentation only if the facility has defining policy and procedure.....

I finished a case involving a nurse who did not document as she thought was appropriate just because the facility did not have Policy/procedures for the documentation.

The facility was found negligent for not providing appropriate P/P regarding proper documentation and the nurse was liable for not providing adequate documentation despite lack of facility P/P.

Thank you for giving a very vivid and concise answer, Siri. I appreciate your expertise! You and I---we need to sit down and have a long talk sometime. I am sure there is SO much I can learn from you.

Smilin', it would be an honor to converse with you. You are so vitally in tune with the legalities of nursing. I am sure you would make an expert Expert Witness.

I have considered doing what you do, one day. I would love to help others help themselves. I have a lot of respect for your work. I need more education, first. I am so torn. I wish I could be a midwife, too.

And, midwife you should pursue. You know how I/we feel about that subject. As for the LNC..... You already are an expert on that subject and have so much more to offer in the field of legal nursing. Your ability to express yourself in the medical-legal terms required in this field far surpasses many LNC's I have met who are certified and actually working. You do not learn this in school, Smilin'. It comes naturally and with that special thirst to practice in this area.

There off my soap box. Back to the topic.